Virginia’s psychiatric hospitals are dangerously full. Though considered safest when operating at 85 percent capacity, often nearly every single bed is taken.
Yet at any given time, many of those patients have been deemed ready for discharge, but they remain in the hospital because they have nowhere else to go.
In May, there were 246 people on the state’s Extraordinary Barriers to Discharge List, meaning some extenuating circumstance has prevented them from leaving the hospital, most often because there is no appropriate provider or facility in their community able to offer them care. May marked the largest the list has been in the past five years.
In total for the 2019 fiscal year, there was an average of 186.7 people on the list, compared to 167.2 in 2018 and 186.6 in 2017, said Daniel Herr, deputy commissioner for facility services with the Department of Health and Developmental Services.
The list illustrates the numerous pressures squeezing state hospitals. Not only have they seen a huge influx of admissions over the last five years, they have also consistently had trouble finding a place for those patients to go once their treatment is complete.
The core challenge in Virginia, Herr said, is that the state divides its funds about equally between crisis services, including state hospitals, and community services. Most other states invest 75 percent of their funds into the community and only 25 percent in the state hospitals.
Advocates often argue that the problem is twofold: There aren’t enough community services to prevent people from experiencing psychiatric crises in the first place, and there aren’t enough places for them to stay, either long-term or as a transitional option, in the community once they finish their treatment in the hospital.
“Hundreds of individuals are being held in violation of their constitutional rights,” said Colleen Miller, executive director of the disAbility Law Center of Virginia, which released a report on the discharge list last month. “This is the highest number of people we have ever seen who are ready to move to the community and can’t because the community is not resourced enough to meet those needs.”
Lingering in the hospital
In May, 18 percent of all adult residents receiving care in one of the state’s psychiatric hospitals were on the Extraordinary Barriers to Discharge list, according to the report.
Herr noted that there were about 20 fewer patients on the list in June and said that, while the size of the list is concerning, May was likely an outlier.
But on average there are more than 100 people stuck in the hospital even though their clinicians have said they’re ready for discharge.
“I can’t imagine what that would do for that individual’s mental health,” said Rhonda Thissen, executive director of the National Alliance on Mental Illness of Virginia. “They’re around people who are still in crisis, or that need long-term care, and this person is ready to go home and ready to be out and live a normal life in the community.”
Ultimately, lingering in the hospital for weeks on end can potentially undo the work that patients may have completed in the hospital, Herr said.
It can deteriorate trust between patients and therapeutic providers because they might think their caregivers aren’t doing enough to help them make the transition out of the hospital.
It could even result in behaviors that might get in the way of their discharge.
“If someone started anger management or has a history of aggression and, in a period of being frustrated or angry, does something in the hospital — all these things can then actually delay the discharge,” Herr said. “For some individuals, it can actually increase the psychiatric symptoms that brought them into the hospital in the first place because of the stress and frustration it can cause.”
Each of the individuals on the Extraordinary Barriers to Discharge List has been waiting to be discharged for at least two weeks. But on average, people are on the list for more than four months, according to the disAbility Law Center of Virginia report.
The barriers themselves vary. Typically, between 50 and 60 of the people on the Extraordinary Barriers to Discharge List have received a not guilty by reason of insanity acquittal, as well. Finding placements for them after they leave the hospital is especially complex, Herr said, because the court is also involved in their cases.
And often those patients, like the rest of the people on the extraordinary barriers list, require providers who can handle their situations.
The patients may have not only a psychiatric diagnosis, but also a substance use disorder, a developmental disability or a complex medical condition.
“Finding providers with specialized skill sets to do all that is always an issue,” Herr said.
Most often, people on the list are waiting for a nursing home or assisted living facility that will take them — housing is a major challenge for people with mental illness in Virginia. They often cycle between unstable housing, homelessness, jail and the hospital.
“These housing issues are really problematic,” Thissen said.
Nursing homes and assisted living facilities can refuse to accept patients, depending on their histories. Virginia has grappled with the problem of housing and mental illness for years, often relying on assisted living facilities who accept recipients of Virginia’s auxiliary grant program to take people with serious mental illness.
But there are fewer and fewer facilities accepting auxiliary grants, with operators often arguing the reimbursement is too low. In 2017, fewer than 300 of the 580 licensed assisted living facilities in the state accepted auxiliary grant residents, according to the Department for Aging and Rehabilitative Services, which administers the program. And many of the facilities that accept the program often only take a limited number of residents.
‘There is something deeply broken’
Over the past several years, Virginia’s lawmakers have pumped millions of dollars into the state’s mental health system to attempt to shift more money into community services — to keep people out of the hospital in the first place.
The General Assembly has devoted more money to addressing the Extraordinary Barriers to Discharge list, Herr said. In 2015, the Department of Behavioral Health and Developmental Services had $22 million in discharge assistance funds to help people transition out of the hospital, but for the 2020 fiscal year it has more $32 million.
But there is still a long way to go. In April, May and June of this year, the state hospitals were operating at 97 and 98 percent capacity, Herr said.
With the discharge list spiking in May, advocates are pointing again to housing as a major priority. The evidence-based model known as permanent supportive housing is often lauded as the best option for people with serious mental illness. It allows the resident to choose her or his own independent housing, but surrounds them with the services they need, like case management and counseling, so they can remain stably housed.
Lawmakers put $5 million toward permanent supportive housing this year and has allowed auxiliary grant recipients to transition into it, as well.
“If we had more of those services in the community, moving those people on and upward into permanent supportive housing frees up nursing homes and assisted living facility beds for the folks coming out of the state hospital who need them,” Thissen said.
That would alleviate the Extraordinary Barriers to Discharge list — and get people out of the hospital who no longer need to be there.
“They’re in a very condensed congregate setting, which is not the way any of us do well, not the way any of us thrive,” Miller said. “There is something deeply broken in the system.”